Drafted and sent into combat training at the age of 19, having just finished high school, Barron Hall fought in Vietnam and returned home to a foreign land.
“Instead of … getting a college education, I learned how to kill just well enough to survive,” said Hall. “The hardest part was leaving my friends and family, only to come home to something totally different. Drugs, guns, and violence had crept in. My worst day of combat didn’t compare to my most fearful day back home.”
There are various difficulties one must face when transitioning from combat, back into civilian life, Hall explained. He received his formal discharge in 1969, but did not receive help for his Post Traumatic Stress Disorder (PTSD) until 1993.
“Some of the atrocities we committed just to come home alive were unforgivable. We feared that that violence would follow us back,” said Hall. “It’s only the grace of God that has me here alive, and out of prison.”
Exposure to extremely traumatic events, namely those related to violence, may lead to the development of PTSD. The Anxiety and Depression Association of America (ADAA) found that 7.7 million adult citizens have diagnosed cases of PTSD.
“This event turns someone’s life upside down and it’s completely outside of their control,” said Dr. Jessica Hamblen, Deputy Director of Education for the National Center for PTSD.
Hamblen discusses PTSD in-depth during her narration of an educational tool on PTSD, presented by the National Center for PTSD and the U.S. Department of Veterans Affairs.
“It’s adaptive for people to have strong reactions to traumatic events. It’s protective; it helps us respond under threat. What we want to see is that these reactions decrease over time, when the threat is no longer present,” said Hamblen. “Unfortunately, people with PTSD continue to experience these extreme reactions even when the threat is not present.”
On June 1, 2015, the commencement of PTSD Awareness Month, a final rule amending the medical criteria regarding the eligibility for the Health Care for Homeless Veterans program (HCHV) took effect. Prior to June 1, homeless veterans did not qualify for the HCHV program unless they had been diagnosed with a serious mental illness, such as PTSD, or had a substance use disorder. That requirement has been removed, now allowing all homeless veterans who qualify for VA healthcare to participate in the HCHV program.
The initial proposition to amend the eligibility for HCHV was outlined in a document published by the Federal Register on May 15, 2014. The VA was urged to seek funding and resources to account for the inevitable increase in HCHV enrollment that would result from the amended ruling. One commenter worried that this alteration would put homeless veterans with mental illness or substance use disorders at a disadvantage.
The concern was that providers may find it easier to aid the homeless veterans without mental health issues or substance use disorders and unintentionally neglect those veterans the program was originally stipulated for. Conversely, veterans with undiagnosed cases of PTSD will now also benefit from HCHV.
The American Psychiatric Association defines the criteria for a PTSD diagnoses as having a definable stressor; intentional avoidance of stimuli relating to the trauma; and negative changes in cognitions and mood that begin, or are worsened, after a traumatic event; among other criteria that are taken into consideration.
PTSD is a theme often associated with veteran homelessness. Though little research has been done to quantify the relationship between PTSD and general homelessness, it is a growing topic of public discourse.
Dr. Stephen Metraux, Associate Professor of Health Policy and Public Health from University of the Sciences in Philadelphia, conducted a study published in December of 2013 that explored PTSD as a risk factor for homelessness among veterans. Metraux and fellow researchers concluded that PTSD is, in fact, a risk factor for homelessness, but not to the extent that the public may perceive.
“There is not much research on the relationship of military PTSD and homelessness,” Metraux told Street Sense in an interview. “As far as I know, my study is the first to find PTSD as a risk factor for homelessness, although, as I point out in the study, the increased risk for homelessness associated with PTSD is not particularly high.”
In determining whether PTSD increases the likelihood of homelessness, Metraux believes not enough is known to develop an educated conclusion.
“There is a popular stereotype of the veteran becoming homeless as a result of fighting his/her ‘inner demons’ and not being able to readjust to civilian life, in essence ending up on the street while still immersed in his/her own war,” Matraux said. “This is not untrue, in that there are high levels of PTSD in the homeless veteran population.”
Throughout Metraux’s research, a pattern began to develop, particularly involving veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). When explaining their homelessness, OIF and OEF veterans usually offered a failed relationship as the main cause of their homelessness. These veterans rarely point towards behavioral health issues as the root cause, according to Metraux.
“It is not so much that they are trying to hide such conditions,” Metraux said. “My impression is that they see [behavioral health issues] more as things they have to deal with and that they shouldn’t interfere with regaining housing, employment, etc,” Metraux explained.
Although PTSD, as it relates to homelessness, is often discussed in regards to the homeless or at-risk veteran population, the trauma that can accompany experiences of homelessness also make it a viable etiology of PTSD.
“Homelessness itself may be traumatic, but homeless people are also at greater risk of being assaulted, victimized, and mistreated in various ways. Having safe places for homeless people to recover is important,” said Dr. Jack Tsai, Editor-in-Chief for the Journal of Social Distress and the Homeless. Tsai, a Yale faculty member, directs the Yale Division of Mental Health Services and Treatment Outcomes Research and also has a research appointment at the Department of Veteran Affairs.
Though minimal research is available to point to PTSD as a cause for homelessness, Tsai believes that it may be a less conspicuous cause. PTSD can lead to various other issues, such as substance abuse, that have been better linked to homelessness, according to Tsai. Regardless of the findings to date, researchers agree that homelessness and PTSD can tread on common ground. Substantial research is still needed to determine how much ground that is.
“I would say that PTSD is as likely to develop after homelessness as it is to precede it.” Tsai said. “I think something not often discussed is safety in the shelters, transitional housing, and other housing arrangements for homeless people.”
